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CEDAR CREST HOSPITAL & RTC 3500 SOUTH IH-35 BELTON, TX June 4, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on a review of the clinical record the use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under 482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law.

Findings were:

Patient #1's clinical record was reviewed on the morning of 06/04/2018 in the hospital conference room. Review of the "Precaution/Observation Checklist" dated "2/25/18" stated in part "Pt was cursing the staff and saying she was going to hit staff in the cruch and then tried to attack staff. Pt. was escorted to gr to calm down. Pt then attempt to punch staff. Pt was restrained and pulled in qr. Pt. calmed down. Will cont. to monitor." The review found no time documented by the MHA in the "Shift note".
A review of physician orders for patient #1 revealed no order for a physical restraint. There was no other required restraint documentation paperwork in patient #1's chart. A review of an incident report dated 2/25/2018 did not document that patient #1 had been physically restrained. The incident report log did not document a physical restraint for Patient #1.
A review of "Provider Progress Note" for Patient #1 dated 2/26/18 at 8:20am documents in part that "(Patient #1) reported she got restrained over the weekend. She punched the staff as a result of anger."
An interview was conducted with the Quality Assurance Registered Nurse (RN), Staff #3 on 06/04/2018 at approximately 11:00 am in a facility conference room. Staff #3 was asked about the facility's restraint policy. He stated that if a patient is restrained the physician must order the restraint. He was asked about the documentation made by a mental health aide (MHA) found in the chart of Patient #1 that stated the patient was restrained and placed in the quiet room on 02/25/2018. Staff #3 acknowledged there was no documented time of the MHA's note. He also acknowledged there was no physician order, restraint packet, and no observation sheet for the Quiet Room. He stated there is a special restraint packet must be completed by the RN. Staff #3 stated the packet includes physician orders, observation sheet, and a debriefing form.

An interview was conducted on 06/04/2018 at approximately 11:20 am in a facility conference room with the Nursing Supervisor, Staff #4. He was asked about the hospital restraint policy and procedure. Staff #4 stated "They should have called a Code Yellow. They should attempt de-escalation measures and then physical restraint as a last resort. The physician should be called for a restraint order and to obtain medications to calm the patient." Staff #4 acknowledged there was no "As Needed (PRN) medications for de-escalation purposes documented in Patient #1's chart.
An interview was conducted on 06/04/2018 at approximately 11:40 am in a facility conference room with Registered Nurse, Staff #5. She was asked if she knew anything about the documented restraint and the placement of Patient #1 into the unit Quiet Room on 02/25/2018. Staff #5 stated "I don't remember the incident." She reviewed her nurse note for the shift of 02/25/2018 and acknowledged there was nothing documented about a restraint. Staff #5 stated "If you write restraint in the chart I have to fill out the 7-page restraint packet."

A phone call was made by the Nursing Supervisor, Staff #4 to Mental Health Aide (MHA), Staff #6, on 06/04/2018 at approximately 11:45 am. Staff #4 asked Staff #6 "Do you remember anything about a (Patient #1) that was admitted to the unit? Staff #6 stated "No. I don't remember anything about that name. I don't recognize the name at all." Staff #4 told her the patient was admitted in February 2018 and that she had documented that she had to restrain her. Staff #6 stated "In February. I don't remember it at all."

An interview was conducted on 06/04/2018 at approximately 12:55 pm in a facility conference room with a Master Social Worker (MSW), Staff #7. She was asked if she remembered the (Patient #1)? Staff #7 stated she had been told that Patient #1 had punched a wall on the unit and she had tried to contact the patient's parents to tell them about the incident and to discuss that Patient #1's treatment plan goals had been updated." When Staff #7 was asked if she remembered anything about Patient #1 being restrained, she stated she had not heard anything about a restraint.

The facility policy 1000.44 titled "Physical Restraint" Revised 2/18 states in part "POLICY: Physical Restraint is an emergency behavioral intervention of last resort in which preventive and de-escalation techniques have been attempted and/or considered and determined to be ineffective and it is immediately necessary to restrain the patient in order to prevent harm to self and others." The policy also stated "All physical restraints require a physician's order. If the physician is not present, a Clinically Privileged RN may initiate the intervention. In this case, an order must be obtained from a physician no later than one hour following the implementation of the intervention."
Procedure:
7. Clinically Competent Registered Nurse's Responsibilities
7.2 The RN must secure a Physician's Order whether in person, verbal or Telephone Order (with appropriate "Read Back" procedures as per policy) from the physician as soon as possible following a restraint incident.
7.3 The RN will sign, date time and complete the Physician Orders.
7.4 The RN should complete the Restraint Documentation Form.
7.5 The RN should ascertain appropriate "Debriefing" of the restraint incident with the patient and staff involved in the episode as soon as possible with subsequent documentation ..."

The facility document titled "Patient Rights" states in part:
Patient rights:
...
Respect and Dignity
-To receive considerate and respectful care at all times and under all circumstances, with recognition of my personal dignity.
Personal Safety
-To expect reasonable safety in so far as the hospital practices and environment are concerned, including the right to be free from all forms of abuse or harassment.
Seclusion and Restraints
-To be free from seclusion and restraints of any form that are not medically necessary or are used by the staff as a means of coercion, discipline, convenience, or retaliation.
Basic Rights
1. You have the right to be treated with respect and dignity in a place that is clean and where you are protected from harm.
Care and Treatment
17. You have the right not to be physically restrained (restriction of movement of your body be person or by a device or by being locked in a room alone) unless your doctor says it is necessary. However, if there is a situation in which staff thinks you may hurt yourself or someone else if you aren't restrained right away, you can be restrained for up to an hour before the doctor's permission is given. Whenever you are restrained, staff has to tell you why you are being restrained, how long you'll be restrained, and what you need to do to be removed from restraint sooner."

The above findings were acknowledged in an interview with the Quality Assurance RN, Staff #3 and other nursing staff on 06/04/2018 at approximately 11:00 am in a facility conference room.